MGDC Patient Scheduling Form
This form must be submitted to Michigan Geriatric Dental Care (MGDC) prior to scheduling. You can contact MGDC at: mgdc@drmarymfisher.com and 248-932-9243 (Voicemail line).
Patient's Full Name:
*
First Name
Middle Name
Last Name
Patient's Date of Birth:
*
-
Month
-
Day
Year
Date
Name of Community:
*
If patient lives at home please put the address.
Room Number:
*
If patient lives at home put N/A
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Responsible Party
All information on this page should be regarding to the responsible party, guardian, Financial POA, POA, or conservator
Guardian Name:
*
First Name
Last Name
Relation to Patient:
*
Billing Address of Financial POA to send statement:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Billing Email of financial POA to send statement:
*
example@example.com
The best phone number for Dr. Fisher to reach POA during the appointment:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Alternate Number if we cannot reach you at first number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
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Patient Health Information
Patient allergies (Ex: Latex, Penicillin, Mycins, Sulfa, Anesthetic, etc.....):
*
Does the patient have any joint replacements? (Ex: Knee, Hip, Shoulder OR Pins, Plates, Rods):
Date of Surgery for joint replacement or surgery above:
-
Month
-
Day
Year
Date
Does the patient have any of the following? Heart Murmur, Pacemaker, Atrial Fibrillation (A-Fib), Mitral Valve Prolapse (MVP):
Has the patient had Heart Valve Replacement(HVR), or Congestive Heart Failure (CHF)? if so, which?
Date of HVR or CHF:
-
Month
-
Day
Year
Date
Has the patient had any Strokes or Seizures:
Date of last Stroke or Seizure:
-
Month
-
Day
Year
Date
Has the patient had any stents, ports, or heart bypass surgery?
Date of stent, port, or heart bypass surgery:
-
Month
-
Day
Year
Date
Is the patient on blood thinners? (Ex: Coumadin, Plavix, Warfarin, Eliquis, Pradaxa, Xarelto, etc....)
*
Does the patient take daily aspirin? If so, is it 81mg or 325 mg?
*
Is the patient diabetic? Insulin or Non-Insulin Dependent?
*
Ex: Yes, Non-Insulin Dependent
Does the patient have their own teeth or partials/full dentures? Please Explain in detail:
*
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Patient Dental Insurance
Does the patient have dental insurance?
*
Name of carrier:
Group number:
Member ID number:
Front of insurance card (if available):
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Back of insurance card (if available):
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Responsible Party's Signature
Responsible Party's Signature:
*
Responsible Party's Name:
*
First Name
Last Name
Today's Date:
*
-
Month
-
Day
Year
Date
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Should be Empty: